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Neonatal resuscitation (NNR)
Dr. Renu Singh
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Burden of the problem Birth asphyxia
23% of the 1 million neonatal deaths in India Long term neurological complications Death NNR (Neonatal resuscitation) :simple, inexpensive, cost effective method Problem: NNR often not initiated, incorrect use of methods
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Successful NNR: factors
Anticipation: call a skilled personnel Adequate preparation Accurate evaluation, algorithm based Prompt initiation of support
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1.Anticipation: High risk delivery
Maternal condition Advanced maternal age ,DM, HT, stillbirth, fetal loss, early neonatal death Fetal condition Prematurity, post maturity, congenital anomalies, multiple gestations Ante partum complications: APH, oligo /polyhydramnios Delivery complications Malpresentation, MSAF, instrumental delivery, antenatal asphyxia with abnormal FHR
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2. Adequate preparation Radiant warmer is turned on,& is heating
Oxygen source is open with adequate flow through the tubing Suction apparatus tested, functioning properly Laryngoscope is functional with bright light Resuscitation bag & mask demonstrates an adequate seal & generation of pressure
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Radiant warmer
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Successful NNR: factors
Anticipation: call a skilled personnel Adequate preparation Accurate evaluation, algorithm based Prompt initiation of support
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Evaluation, algorithm based
Rapid assessment of neonate clinical status Is the infant full term? Is the infant breathing or crying? Does the infant has good muscle tone? Yes: no resuscitation, routine neonatal care No: needs resuscitation
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Approach to resuscitation 2010 AHA, AAP
A: initial steps(provide warmth, clear airway if necessary, dry, stimulate) B: breathing(ventilation) C: chest compressions (circulation) D: administration of drugs &/or volume expansion
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Resuscitation: initial steps
Provide warmth Head position “ sniffing position” Clearing the airway, if necessary Drying the baby Tactile stimulation for breathing
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AAP Algorithm
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AAP Algorithm
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PPV: Positive pressure ventilation
Form of assisted ventilation Needed when there is no improvement in HR Also assess chest wall movements Should be delivered at rate of breaths /min, maintain HR>100 /min Devices: BMV, ET (endotracheal tube),LMA(laryngeal mask airway)
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Bag & mask ventilation
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Endotracheal tube If BMV is ineffective/prolonged
When chest compressions are performed Initial endotracheal suctioning of non vigorous meconium stained newborn
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Endotracheal tube
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LMA(Laryngeal mask airway)
Soft mask, fits over laryngeal inlet when inflated, occludes the oesophageal opening Done when BMV is unsuccessful & tracheal intubation is unsuccessful or not feasible
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LMA(Laryngeal mask airway)
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Targeted SPO2 after birth
1 minute 60-65% 2 minutes 65-70% 3 minutes 70-75% 4 minutes 75-80% 5 minutes 80-85% 10 minutes 85-90%
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Initial steps in resuscitation
PPV
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AAP Algorithm
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Chest compressions Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec Delivered at lower third of sternum, to depth 1/3 of AP diameter of chest 2 techniques: 2 thumb-encircling hands technique Compression with 2 fingers ,second hand supporting the back 3:1 ratio::[ 90 comp:30 ventilations]
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Initial steps of resuscitation
PPV(ET) CHEST COMPRESSIONS
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AAP Algorithm
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Medications Rarely indicated
Most important step to treat bradycardia is establishing adequate ventilation HR remains <60bpm,despite adequate ventilation(ET) with 100% Oxygen & chest compressions Epinephrine or volume expansion or both
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Epinephrine Route of administration: intravenous(IV),ideal
Recommended dose: mg/kg per dose Desired concentration: 1:10,000 0.1 mg/ml
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Volume expansion Suspected or known blood loss
Isotonic crystalloid solution ; normal saline Blood Dose calculation: 10 ml/kg
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Give oxygen as necessary Positive pressure ventilation
Asses if resuscitation is needed, keep warm, position, clear, dry, stimulation Give oxygen as necessary Positive pressure ventilation Endotracheal intubation Chest compression drugs
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The golden minute <30 seconds: complete initial steps
Warmth Drying Clear airway if necessary Stimulate 30-60 seconds: assess 2 vital characteristics Respiration (apnea/gasping/labored/unlabored) Heart rate (<100/>100bpm) Golden Minute Project: skill based training
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AAP Algorithm
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Post resuscitation care
Needed for those who required PPV At risk of deterioration Hypo/hyperthermia ,hypoglycemia, CNS complications(apnea, HIE), pulmonary complications(TTN, Pneumonia), hypotension Need monitoring ,evaluation NICU may be necessary
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NNR : not indicated Conditions with certainly early death
Extreme prematurity(GA<23 weeks) Birth weight<400g Anencephaly Chromosomal abnormality: Trisomy 13
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NNR: nearly always indicated
High rate of survival Acceptable morbidity GA≥ 25 weeks Those with most congenital malformations
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NNR? Conditions associated with uncertain prognosis
Survival borderline Parental desires concerning initiation of resuscitation should be supported
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Discontinuing resuscitative efforts
Newborn with no detectable heart rate, consider stopping NNR if the heart rate remains undetectable for 10 minutes
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Summary Most infants transfer from intrauterine to extra uterine life
10% need some intervention,1% need extensive resuscitation Anticipate the need for NNR Adequate preparation for NNR Evaluate the newborn as per AHA/AAP guidelines & follow the recommended protocol
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MCQ1 For successful neonatal resuscitation following is/are needed except: Anticipation Adequate preparation Skilled personnel Delayed initiation of support
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MCQ1 For successful neonatal resuscitation following is/are needed except: Anticipation Adequate preparation Skilled personnel Delayed initiation of support
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MCQ2 Following are true in relation to initial steps of neonatal resuscitation except Provide warmth Tactile stimulation Endotracheal intubation Drying the baby
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MCQ2 Following are true in relation to initial steps of neonatal resuscitation except Provide warmth Tactile stimulation Endotracheal intubation Drying the baby
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MCQ3 The following is the primary measure of adequate ventilation
Chest wall movement Improvement in heart rate Pink extremities Spo2 of 100%
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MCQ3 The following is the primary measure of adequate ventilation
Chest wall movement Improvement in heart rate Pink extremities Spo2 of 100%
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MCQ4 Endotracheal intubation may be indicated at several points during neonatal resuscitation except Ineffective BMV During chest compressions Vigorous meconium stained newborn Non vigorous meconium stained newborn
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MCQ4 Endotracheal intubation may be indicated at several points during neonatal resuscitation except Ineffective BMV During chest compressions Vigorous meconium stained newborn Non vigorous meconium stained newborn
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MCQ5 The recommended compression to ventilation ratio in neonatal resuscitation is 2:1 3:1 4:1 5:1
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MCQ5 The recommended compression to ventilation ratio in neonatal resuscitation is 2:1 3:1 4:1 5:1
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MCQ6 The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation ,IV ,IM ,1V ,IV
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MCQ6 The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation is ,IV ,IM ,1V ,IV
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MCQ7 Recommended method/clinical indicator of confirming ET placement is Condensation in ET Chest movement Equal breath sounds on auscultation Exhaled C Detection
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MCQ7 Recommended method/clinical indicator of confirming ET placement is Condensation in ET Chest movement Equal breath sounds on auscultation Exhaled C Detection
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